Medicare Delays a Full Crackdown on Private Health Plans


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The Biden administration on Friday finalized new rules meant to cut down on widespread overbilling by private Medicare Advantage insurance plans, but softened the approach after intense lobbying by the industry.

Regulators are still moving forward with rules that will lower payments to insurers by billions of dollars a year. But they will phase in the changes over three years, rather than all at once, and that will lessen the immediate effects.

In the short term, private health plans will still be able to receive payments that Medicare officials do not think are appropriate. The system will eventually eliminate extra funds the plans receive for covering patients under 2,000 diagnoses, including 75 that appear to be the subject of widespread manipulation by the plans.

But the extended timetable could also mitigate concerns raised by health plans, doctors and others that the broad policy change might result in unintended consequences, such as increases in premiums or reductions in benefits for Medicare Advantage beneficiaries.

The nation’s top Medicare official acknowledged on Friday that the industry’s feedback influenced the shape of the new rules.

We were really comfortable in our policies, but we always want to hear what stakeholders have to say,” said Chiquita Brooks-LaSure, the administrator of the Centers for Medicare and Medicaid Services. She said desire for a slower policy change was “something that we really heard come through from our comments, and we wanted to be responsive.”

The new payment formula is a reaction to mounting evidence over more than a decade that private insurers have been exploiting a payment formula to extract overpayments from the federal government. Plans are eligible for extra payments for patients whose illnesses could be costlier to cover, which has encouraged many plans to go to great lengths to diagnose their customers with as many health conditions as possible. Insurers are collecting tens of billions of dollars in extra payments a year, according to various estimates.

Nearly every large insurer in the program has settled or is facing a federal fraud lawsuit for such conduct. Evidence of the overpayments has been documented by academic studies. government watchdog reports and plan audits.

Medicare Advantage now enrolls about half of all Medicare beneficiaries. It is popular among its customers, who often enjoy lower premiums and benefits — like vision and dental services — that the basic government Medicare plan doesn’t include.

The program has also become profitable for the largest insurance companies. Recent research from the Kaiser Family Foundation found that insurers make about double the gross margins with Medicare plans that they make with their other lines of business. Humana recently announced that it would stop offering commercial insurance to focus on Medicare, which serves older and disabled Americans, and Medicaid, which mostly serves low-income populations.

The new rule will eventually eliminate the extra payments for many diagnoses that Medicare Advantage plans were commonly reporting, but which Medicare data did not show were associated with more medical care. Those diagnosis codes included a few that private plans had specifically targeted, like diabetes “with complications” and a form of severe malnutrition that is typically seen in countries experiencing famine.

With the three-year phase-in, insurers will receive payments that are based on one-third of the new formula in the first year, and two-thirds on the old one. Altogether, Medicare estimates that Medicare Advantage plans will be paid 3.32 percent more next year than this year. Under the original limits proposed by the administration, that increase would have been around 1 percent. Previous changes in the payment model have also taken three years.

In the two months since the change was proposed, insurers and their allies have engaged in an extensive and expensive lobbying effort, including television commercials, letter-writing campaigns and many meetings with lawmakers and regulators. Several congressional aides said Humana and UnitedHealth, the two largest companies in the program, had been particularly active. Doctors’ groups that have close business relationships with the plans also joined the effort.

The policy’s opponents have argued that the change could erode benefits for the plans’ customers, and might have a disproportionate impact on poor and minority populations.

But the new formula had also been criticized by some advocates and experts as too timid. The Medicare Payment Advisory Commission, which recommends policies to Congress, wrote in a comment letter that the proposed changes, while “directionally correct, are insufficient to address the magnitude of excess Medicare spending.”

Ms. Brooks-LaSure said she did not feel that Medicare was bowing to industry pressure. “We are very comfortable where we have landed,” she said.

The payment change is one of a series of tough rules for the program recently proposed or completed by the administration. Another proposal would place tighter controls on industry marketing and make it harder for plans to deny care to patients. And a rule finalized in January requires the plans to repay the government for a greater share of overpayments uncovered through audits.

Though the Medicare Advantage program has long enjoyed strong bipartisan support on Capitol Hill, few leading lawmakers have stepped forward in this round to defend the plans, despite all the lobbying. Republicans on committees that oversee the programs wrote letters to Medicare officials asking technical questions about the change, but they avoided strong criticism of the policy. On Tuesday, 17 House Democrats sent Medicare officials a letter asking them to delay implementation, but not cancel it.

Bill Cassidy of Louisiana, a physician who is the top Republican on the Senate Health, Education, Labor and Pensions Committee, and Senator Jeff Merkley, a Democrat from Oregon, introduced legislation on Tuesday that would take further steps to prevent “unreasonable payments, coding or diagnoses.”


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